Welcome, Comrade Patient

Welcome, Comrade Patient

By Kim Bellard, December 14, 2017


Capitalism is in big trouble, even in the U.S. and especially among millennials.  So reports Fast Company and The New York Times.  Even capitalism-friendly publications like The Wall Street Journaland Bloomberg warn about it. 

The oft-cited reasons include problems like increasing income/wealthy inequity and dimmer outlook for good jobs, but I have to wonder how much of a role our health care system plays in these kinds of attitudes.


The WSJ also showed a 2016 Gallop poll in which capitalism and socialism were rated equally favorably (both just over 50%) by respondents ages 18 - 29, which was a stark contrast to every other age group (support for capitalism goes up by age, while support for socialism declines).  Similarly, a 2017 WSJ/NBC News survey found that the 18-29 age group was much more likely to say the government should do more to help people, again in contrast to other age groups. 

In some ways, the U.S. health care system is a model of capitalism.  Lots of people are making lots of money, whether they be stockholders in health companiesdoctors and health care executives, or even supposedly non-profit parts of the system. 

The problem is, though, unless you are one of the lucky ones doing well with our current system -- and maybe even then -- you're probably not too happy with it. 

Last year, Senator Bernie Sanders made unexpected headway in his race to be the Democratic candidate for President despite -- or perhaps because of -- his socialist leanings.  One of his key planks was for Medicare for all, an idea that has seen a strong resurgence generally.  Even more popular is the (admittedly vague) push for single payor.

Harvard-Harris poll found that 52% of Americans supported a single payor system, with even 35% of Republicans supporting.  Young people were most supportive.   Perhaps most astonishing is that a Merritt-Hawkins survey found that 56% of physicians now support single payor, a sharp reversal from prior surveys.  42% voiced strong support.

Right now, millennials are not as engaged in health care as older age groups because they tend to need it less.  They don't have as many health problems and don't see health professionals as often.  That's why getting them to buy health insurance is a constant struggle, even when they have the lowest premiums.   

But as this radicalized generation, who are already frustrated with economic inequity and the prospects for their future, realize how much they will have to pay for older Americans' health needs as well as for their own, push will eventually come to shove. 


We have some hard thinking to do about how we finance health care, and for whom.  We have some hard thinking about what the role of profit, competition, and capitalism should be in our health care system.  We have some hard thinking to do about why our health care system is not serving more of us better.

It may not be socialized medicine.  It may not be single payor.  It may not even be Medicare-for-all.  But it for sure will not be what we have now. 


This post is an abridged version of the posting in Kim Bellard’s blogsite. Click here to read the full posting


Friday Five: Top 5 healthcare business news items from the MCOL Weekend edition

Friday Five: Top 5 healthcare business news items from the MCOL Weekend edition

Every business day, MCOL posts feature stories making news on the business of health care. Here are five we think are particularly important for this week:


House tax writers weigh plan to suspend Obamacare insurer tax

House Republican tax writers are considering delaying Obamacare's health insurance tax for only limited markets next year, leaving out small businesses and possibly private Medicaid plans, according to sources on and off Capitol Hill. They would suspend it for all markets in 2019.


Thursday, December 7, 2017

Hospitals Find Asthma Hot Spots More Profitable To Neglect Than Fix

Months of reporting and rich hospital data portray life in the worst asthma hot spot in one of the worst asthma cities: Baltimore. The medical system knows how to help. But there’s no money in it.

Kaiser Health News

Wednesday, December 6, 2017

Providers See CMS Continuing Value-Based Care Push Despite Project Rollbacks

Though the Trump administration last week rolled back several Obama-era projects designed to shift the U.S. health care system away from fee-for-service care to models that pay doctors and hospitals based on the quality of care, industry groups believe the government is likely to continue with the push toward value-based care.

Morning Consult

Tuesday, December 5, 2017

States get big Medicaid savings from social services, outreach to sickest patients

Some states have achieved dramatic savings in health care costs for their sickest Medicaid patients by providing intensive one-on-one assistance and social services that help the patients better address their multiple, overlapping ailments.

USA Today

Tuesday, December 5, 2017

CVS likely wants FTC antitrust review, not Justice Department, of Aetna deal

It is uncertain who in the U.S. government will carry out an antitrust review of CVS Health Corp’s (CVS.N) deal to buy health insurer Aetna Inc (AET.N), but the drugstore company is likely hoping the potentially more lenient Federal Trade Commission gets the nod, antitrust experts say.


Tuesday, December 5, 2017

These and more weekly news items on the business of healthcare are featured in the MCOL Weekend edition, along with the MCOL Tidbits, and more, for MCOL Premium level members.


Are your healthcare consumers who they say they are?

By Claire Thayer, December 7, 2017


Verifying healthcare consumer identities has become enormously complex requiring sophisticated advanced authentication technology.  A HIMSS report on Patient Portal Identity Proofing and Authentication, tells us that the National Institute of Standards and Technology (NIST) identifies three factors as the cornerstone of identity authentication:


• Something you know (for example, a password)

• Something you have (for example, an ID badge or a cryptographic key)

• Something you are (for example, a fingerprint or other biometric data)


Multi-factor authentication refers to the use of more than one of the factors listed above, which NIST requires to reach a high level of confidence in authentication.  At least one of the factors must contain a secret that is securely presented to the electronic process that is verifying the user’s identity.  A second factor can be used to protect or activate the first. In this guidance report, the HIMSS Identity Management Task Force suggests that incorporation of smartphones as a second factor into the processes of identity proofing and authentication will significantly improve the security of electronic interactions with patients while minimizing the additional cost and difficulty.

This recent edition of the MCOL Infographic and e-Brief, co-sponsored by LexisNexis, focused on the intricacies, complexities and challenges involved with identity management:



MCOL’s weekly infoGraphoid is a benefit for MCOL Basic members and released each Wednesday as part of the MCOL Daily Factoid e-newsletter distribution service – find out more here.


Reforms and Innovation Needed to Lower Costs and Improve Quality in Healthcare

Reforms and Innovation Needed to Lower Costs and Improve Quality in Healthcare

By: Tomas Gregorio, Senior Executive Director, Healthcare Delivery Systems iLab, New Jersey Innovation Institute

Healthcare in the United States is complicated, inefficient and expensive.  Many individuals and families can no longer afford to see a doctor, fill a prescription or get the most basic medical care without having to sacrifice other essential items such as putting food on the table or paying the mortgage.  These are choices that no American should be forced to make. 

Unfortunately, after seemingly endless attempts at reform, the costs of our healthcare system continue to move steadily higher, impervious to all attempts from the government, private companies or other stakeholders to hold back the ever-rising healthcare tide.

Healthcare, by its very nature, is resistant to change.  Concerns over privacy and safety often delay the sharing of information or adoption of new technologies that could reduce the costs of care. While these issues are valid, they can and must be addressed as the status quo is no longer acceptable.  

This point has not been lost on the U.S. Department of Health and Human Services and the West Health Institute that in a recent whitepaper noted that greater interoperability of healthcare devices alone could help save more than $30 billion a year in wasteful spending.  While the Rand Corporation in an earlier study estimated that full national interoperability could save $77 billion annually.

A national network in which all providers have access to medical records is still many years away however, there are steps being taken right now by the Centers for Medicare & Medicaid Services (CMS)  that promise to have a positive impact on healthcare costs and quality.   The initiatives, “Patients Over Paperwork” and “Meaningful Measures” seek to reduce the regulatory and reporting burden on providers.

Reducing the amount of time physicians spend on paperwork is goal that I am sure would garner 100 percent support in the healthcare community.  Providers spend countless hours filling out forms or checking boxes that in many cases have no obvious benefit for either the physician or the patient. 

Seema Verma, CMS Administrator, noted this problem during remarks on October 30, at a Healthcare Summit when she said, “We publish nearly 11,000 pages of regulations every year. That is a lot of paper, and it’s taking doctors away from what matter most – patients.”

Further, the American Hospital Association recently published a report showing that health systems, hospitals and post-acute care providers spend nearly $39 billion a year (let that sink in for a minute) solely on administrative activities.

CMS is beginning to address this problem by taking on a full scale review of current regulations by asking some very basic and important questions:  What is the purpose of the regulation? Does this regulation help prevent fraud and abuse? Does the regulation have a meaningful impact on patient care, safety and improving outcomes?   This review alone, and a subsequent role back of regulations has the potential to save untold billions of dollars, improve patient care and restore the sanctity of the provider/patient relationship.

CMS’ Measures Management effort is about examining what quality measures should be reported to the government as part of their overall goal of moving our healthcare system from fee-for-service to value-based care.

My organization, The New Jersey Innovation Institute (NJII), fully supports this effort and is partnering with CMS through their Transforming Clinical Practices Initiative (TCPI) that seeks to save more than $1 billion in healthcare costs by the end of 2019 by helping physicians adopt value-based care payment models. NJII has recruited a network of nearly 10,000 physicians to be part of the initiative and we are on pace to save more than $135 million in costs and improve the health of more than 500,000 Medicare patients over the life of the program.

Meaningful Measures will focus on having providers report only on measures that are most vital to providing high quality care and improving outcomes for patients.   In essence, CMS will focus more on results, less on process, and promote a more market driven health care system.

NJII applauds CMS in its efforts to bring innovation to our healthcare system and examine opportunities for advancement.   We encourage healthcare stakeholders at every level to bring their expertise to the table and further the collective effort to lower costs and improve healthcare quality.


The President’s Commission on Combating Drug Addiction and the Opioid Crisis

Sandhya Gardner, MD, Chief Medical Officer, Relias, December 4, 2017

There has been no shortage of attention given to the current opioid abuse and overdose epidemic sweeping the U.S. Near-daily media reports highlight the staggering number of people who are addicted to prescription and illicit opioids and who die from them daily. Nor have suggested remedies been neglected. Federal regulatory agencies, including the FDA and the CDC, professional medical associations, public health organizations, the insurance industry, and others have all recently issued new guidelines and policies on the proper administration of opioids and the treatment of individuals with opioid addiction.

Despite, or perhaps because of this attention, the President’s Commission report was eagerly anticipated. When released in final form on November 1, 2017, the report was widely praised for its comprehensive attention to the many factors that have combined to create the perfect storm that is today’s opioid crisis. There were reservations, however, because the Commission did not recommend any specific funding amounts to implement its recommendations. Moreover, President Trump’s decision to declare the opioid epidemic a public health crisis rather than a national health emergency also meant that no new funding has yet been allocated. The President’s Commission did advocate, however, that an unspecified amount of increased resources be put towards implementing its 56 recommendations.

We will highlight some critique and opinions about these recommendations specifically for healthcare providers and prescribers, organizations, funders and insurers, government and law enforcement agencies, and patients.

Providers and prescribers will see that the recommendations are largely extensions of current practice and therefore are relatively unsurprising. Adopting policies to ensure that patients give informed consent before receiving an opioid is consistent with current practice standards. Physicians should of course always discuss risks, benefits, and alternatives of any intervention they recommend for their patients. The concern here is that the informed consent procedure policies adopted be balanced. Opioids are proven effective analgesics for both acute and, in some instances, chronic pain and there are patients for whom they are clearly indicated. Informed consent procedures should, therefore, not be designed to frighten or discourage patients who need opioids.

Noteworthy, although not a departure from current policies and recommendations, is standardizing guidelines and extending them to specialists. Right now, there is a patchwork of opioid prescribing guidelines that have been created by multiple agencies. Many of them apply only to primary care providers. Currently, some states, like New York, have mandatory opioid continuing education requirements for relicensing and require that prescribers consult the state’s on-line Prescription Drug Monitoring Program (PDMP) before prescribing an opioid. These requirements would be extended to all states and a standardized national opioid prescribing curriculum would be created. It is unclear how effective continuing education programs are in improving opioid prescribing practices, so the benefits must be weighed against the burden it places upon physicians who must spend time taking more courses. Similarly, although there is some evidence that PDMP use reduces opioid abuse, it remains unknown whether this will have a significant effect in stemming opioid abuse.

Physician groups have complained that questions about how pain was handled that are included in patient satisfaction surveys contribute to unnecessary opioid prescribing. Fearing that negative reviews will be held against them; physicians report feeling pressured to prescribe opioids to patients with pain complaints to boost their ratings. The new recommendations mandate that CMS remove pain questions entirely from patient satisfaction surveys. This seems like a very positive step towards reducing inappropriate opioid prescribing.

Current practice is to refer patients reporting to the Emergency Department (ED) with signs and symptoms of opioid abuse or withdrawal to outpatient providers, but this can lead to poor follow-up and/or retention in treatment. Studies have shown that treatment, particularly with medications like buprenorphine/naloxone (Suboxone), can be started in the ED for such patients, who then are much more likely to enter outpatient treatment and remain drug-free for extended periods of time.  Although some emergency physicians in the past have been reluctant to start medication assisted treatment (MAT) for patients in the ED, the recommendation to initiate substance abuse and addiction treatment in the emergency department could substantially improve outcomes for opioid addicted individuals. 

Healthcare insurers will likely see an increase in their costs because of these recommendations. Nevertheless, these recommendations are all consistent with expert opinion. Right now, insurers incentivize physicians to prescribe opioids rather than alternative analgesic interventions, a policy that is widely criticized. For example, it is less expensive for patients to fill a prescription for a generic opioid than it is to have acupuncture or cognitive-behavioral therapy, even though both of the latter are among the non-opioid interventions that can be effective and far less risky in treating pain than opioids. The President’s Commission appropriately recommends modification of rate-setting policies that discourage use of non-opioid treatments for pain. It also calls for insurers to remove barriers for all forms of substance use disorder (SUD) treatment, including MAT. There is widespread agreement among experts that MAT is a safe and effective treatment for SUD and that its use should be expanded significantly. Finally, the recommendations call for stricter enforcement and stiffer penalties for insurers that violate mental health and parity laws. Although this last recommendation will certainly win the approval of advocates, enforcing the parity laws currently in effect has proven to be extremely difficult.

The creation of drug courts in all 93 federal judicial districts has already won widespread approval. Individuals with an SUD who violate parole would be referred to a drug court rather than sent to prison. Sending SUD patients to prison is generally seen as counterproductive and diversion to treatment via drug courts reduces recidivism.

Of course, all the above will have tremendous impact on patients who have pain-related illnesses or who are struggling with problematic opioid use. One recommendation that has not been met with much approbation, however, is for a media campaign to address “the hazards of substance use, the danger of opioids, and the stigma.” Some have criticized this recommendation as being too vague. It is unclear that such a campaign would significantly alter public perception or behavior. It also runs the risk of discouraging people who are legitimately taking opioids for severe pain, such as cancer patients, from adhering to prescribed regimens. The hope is that if a media campaign is pursued, that it is carried out in an evidence-based manner that incorporates what is known from social science about effective methods for changing attitudes and behavior.


The most immediate concern about the President’s Commission report is that no funding is yet attached to its recommendations. One member of the Commission, former Rhode Island congressman Patrick Kennedy, was quoted as estimating that Congress needs to appropriate at least $10 billion immediately for the Commission’s recommendations to be carried out.   

Another concern is whether the President’s Commission report takes into consideration the need to balance medically-indicated opioid prescribing with abuse/overdose prevention. Opioids are effective analgesics that can be a highly appropriate treatment for severe pain in both acute and chronic situations. But there is no question that they are currently prescribed in many situations for which other, less perilous, alternatives are effective and available. Nor is there any disagreement that opioid misuse and abuse have reached epidemic proportions and that the quantity of opioids prescribed must be reduced. However, patients who need to take opioids must not be stigmatized, nor must physicians be frightened to prescribe them when its necessary.

Overall, barring the concerns about funding and some skepticism around the proposed media campaign, the recommendations have been met with optimism. They provide a multi-prong approach to an enormous problem and include many evidence-based recommendations.

For further information on this topic, a free webinar will be taking place on Tuesday, December 12 at 2pm EST. Titled, Opioid Commission Final Report: Recommendations and Effects on Payers, Insurers, and Providers, the webinar will be led by Susan Kansagra, MD, MBA – Section Chief -  North Carolina Division of Public Health, Chronic Disease and Injury Section, North Carolina Department of Health and Human Services, and Jason E. Vogler, Ph.D., CS SBB, Senior Director - Division of Mental Health, Developmental Disabilities and Substance Abuse Services
North Carolina Department of Health and Human Services. Registration for the webinar is available here.